Professional/Technical Component Policy (CES):

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UnitedHealthcare OxfordPolicy Appendix: Applicable Code ListProfessional/Technical Component Policy (CES):CPT/HCPCS CodesThis list of codes applies to the Reimbursement Policy titled Professional/TechnicalComponent Policy (CES).Effective Date: November 1, 2021Applicable CodesThe following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive.The listing of a code does not imply that the service described by the code is a covered or non-covered health service. Benefitcoverage for health services is determined by the member specific benefit plan document and applicable laws that may requirecoverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment.Other Policies may apply.Included in this list:Professional/Technical Component Codes (CMS NPFS PC/TC Indicator 1 Diagnostic Tests)Laboratory Codes (CMS NPFS PC/TC Indicator 3 or 9)Gap Fill CodesASCFS Addendum BB CMS NPFS PC/TC Indicator 1 CodesCPT is a registered trademark of the American Medical AssociationCodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these ional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 1 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these %0.00%51784Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 2 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these %0.00%70120Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 3 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these .00%70260Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 4 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these .00%70380Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 5 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these .00%70492Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 6 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these 0%0.00%70552Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 7 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these 00100.00%0.00%71110Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 8 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these 0.00%0.00%72020Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 9 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these .00%72110Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 10 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these .00%72142Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 11 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these 00%0.00%72193Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 12 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these %0.00%72275Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 13 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these 00%73090Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 14 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these %0.00%73219Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 15 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these 0.00%0.00%73551Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 16 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these .00%73630Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 17 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these .00%0.00%73725Professional/Technical Component Policy (CES): CPT/HCPCS CodesUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 18 of 88Effective 11/01/2021

CodeModifierRVURBRVS SplitRBRVS % SplitRBRVS VarianceProfessional/Technical Component Codes (CMS NPFS PC/TC Indicator 1: Diagnostic Tests)Codes with a CMS NPFS PC/TC Indicator 1 with their percentage splits. These codes have both a Professional Componentand a Technical Component. Modifiers 26 and TC can be used with these .00%0.00%9

Standalone Incident To Codes (CMS NPFS PC/TC Indicator 5) Professional Component Codes (CMS NPFS PC/TC Indicator 6 or 8) Laboratory Codes (CMS NPFS PC/TC Indicator 3 or 9) Codes Subject to the PC/TC Concept Without RVU Splits Gap Fill Codes ASCFS Addendum BB CMS NPFS PC/TC Indicator 1 Codes ASCFS Addendum BB CMS NPFS PC/TC Indicator 3

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